November 27, 2013

Myths and Depression

The Canadian Charger

In a lecture about depression delivered on November 23 at Ottawa's Royal Ottawa Hospital, Dr. Pierre Blier addressed the issue first by tackling certain myths. Blier is the Director of Mood Research at the University of Ottawa and Canadian Research Chair of Psychopharmacology.

His
myth #1: The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the
American Psychiatric Association’s classifications proliferate to sell more
drugs.

On
the contrary, the DSM criteria for depression remain virtually unchanged over 30
years. (The fifth edition has appeared
this year.) Blier thinks that more
change may well be needed, as he believes that the wide range of the criteria
covers more than a single condition.

Myth
#2: Depression is not very important compared to other illnesses.

On
the contrary, it is the condition in moderate and high income nations casing
the greatest losses. Around the world,
it is number three, and he says that by 2030 it will be number one there as
well. And when a person with depression
suffers from some other medical problem, there is a synergistic effect, where
one and one no longer equal two but instead equal three or four or more.

Myth
#3: Anti-depressants are overprescribed.

In
fact, they may be under-prescribed.
Sometimes they are prescribed for anxiety and phobias rather than for
depression, but often prescriptions for depression are prescribed at inadequate
strength.

Myth
#4: Anti-depressants are addictive.

He
might wish it were so. If they were
addictive, people would not stop taking them.
Half who do take them quit, and they usually relapse. When a person relapses and goes back to the
medication, the medication may no longer work.
Lack of maintenance of the medication leads to a weakening of
efficacy.

With
a first episode of depression, the person needs to take medication for at least
six months. If there are further
episodes, such treatment may require many years.

Myth
#5: Depression has little effect on the
body.

Depression
can have substantial impact on physical health.
Sufferers are apt to lose bone density, especially women. They may also suffer neurodegenerative
disorder, especially if they have a number of depressed episodes. Among the elderly, current and past
depression increases the risk of dementia.

Depression
may affect the heart, leading to arrhythmia and increasing the likelihood of
infarction, and of death caused by infarction.

In
pregnancy, depressed women have smaller fetuses. Blier favors treating depressed pregnant
women aggressively, using medications.
“There has been no evidence of harm to the fetus,” he assured us.

Myth
#6: We are born with a set number of
brain cells.

No,
new cells are constantly being produced, even in people older than 70. Brain cell production is increased by use of
anti-depressants, reduction of stress, and electro-convulsive therapy (ECT),
otherwise known as shock treatment.

There
are different chemicals in the brain implicated in mood, and medications
mirroring them are used in treatment.
Broadly, serotonin is involved in impulse control, norepinepherine in
energy, and dopamine in drive, though there are overlapping effects. Combining medications is therefore not
unusual, but it is a balancing act.
While it is important to avoid too many drugs, called polypharmacy, it
is also important to avoid not addressing the problem fully.

Fear
of polypharmacy should not deter the physician from treating depression
aggressively, as it worsens all other medical problems and shrinks the
brain. “In most cases, depression does
not take months to lead to remission because of effective treatments.” And there are new treatments on the
horizon.

Blier
commented on a couple other matters that are not directly related to
depression—on generic drugs and on the shortage of specialists to treat
depression. He reported that generic
drugs can vary from the original, with potency 20% less or 25% greater. In Canada, the situation can be worse. “There are no spot checks in Canada.”

He
pointed to a lack of professionals to treat depression, noting that it is often
dealt with by family physicians. When
asked about using psychiatrists in a consultative role to assist family
practitioners, he said that that is being done in distance medicine for service
to remote areas. When pressed about
providing the same kind of help in urban areas, he was reluctant to take
psychiatrists away from direct practice.
This observer sees that reluctance as a preference among professionals
for providing the service directly rather than a way of maximizing benefit to
the community and to patients.